23D-190 NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of this Contract,signed by both you and the Home Depot,at the time yon
sign. Do not sign a Completion Certificate before the Installation is complete.
Acceptance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer
and The Home Depot with regard to the products and installation services and supersedes all prior discussions and agreements.
either oral or written. relating to said products and installation.This Contract cannot be assigned or amended except by a writing
signed by Customer and The I tome Depot.
Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received
a copy of this Contract. Customer acknowledges receipt of the Notice of Cancellation,and that the Home Depot has orally
informed Customer of Customer's right to cancel. Customer's signature below constitutes Customer's acceptance and
execution of each of the applicable Contract Documents. 1)0 NOT SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES.
You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies
only to this Agreement. By contacting sales office (877)903-3768 ,you may update your email address,withdraw your
consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following:
• You consent to receive only an entailed copy of this Agreement
• You have access to a computer that can receive and open entails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Improvement Contract
Submitted by:
Sales Consultant I'odd Ferrer \
License Name.
Telephone No. (1+77)9t)3-376S i
Sales Consultant Accepted by:TF19(Sep 4,2013,9:39 AM)
License No. (as applicable)
CANCELLATION: CUSTOMER MAY CANCEL THIS CONTRACT WITHOUT PENALTY OR OBLIGATION BY
DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER
SIGNING THIS CONTRACT TO THE ADDRESS LISTED ABOVE. THE STATE SUPPLEMENT ATTACHED
HERETO CONTAINS A FORM')'() USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S
S'T'ATE.
11/30/12-SA Pane 6 7f
Sold.Furnished and Installed by:
71ID
At-Home Services. Inc.
d h a the I tome Depot At-I Ionic Services
905 Roston Turnpike (.'nit I.Shrcvvsburs.Al:A 1545
Toll Free S779033768:Fax 8009S630I0
Branch Name: Boston North Date:9 4 1013 \7L Lit: C 02439 RI Cont. Lice 1042'
(T Lic.:HIC.05055222 \L\ I Ionic Improcrmcnt
Branch No: 13
Contractor Reg. e I26N9; Federal ID
75-269S460
Installation Address: 120 maple Mood tern I lore ice MA 01062
C it∎ State Lip
Purchaser(s): ork Phone: Home Phone: Cell Phone:
Mr. Frank Evans (41;)554-2264l
Home Address: 120 maple wood tern Florence MA 01062
(If different from Installation Address) City State Lip
E-mail Address (to receive project communications and home Depot updates): fexans656S'of aol.com
Marketing emails will not be sent from The Home Depot.
Project Information: Undersigned("Customer"). the owners of the property located at the above installation address. agrees to
buy.and THD At-Home Sen ices. Inc. ("The Home Depot")agrees to furnish.deliver and arrange tar the installation("Installati
on")of all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract
by this reference,along with any applicable State Supplement and Payment Summary attached hereto and an■ Change Orders
(collcetiycly. "Contract"):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
7069409 Rooting 7069409 S 14.7 54.42
Minimum 25% Deposit of Contract Amount
due upon execution of this contract Total Contract Amount S 14.754.42
Customer agrees that. immediately upon completion of the work for each Product. Customer will execute a Completion
Certificate one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each
Customer under this Contract agrees to be jointly and severally obligated and liable. hereunder.
Payment Summary: The I'as ment Suntmars ? '069409 included as part of this Contract. sets forth the total Contnict
amount and payments required for the deposits and final payments by Product Ias applicable).
GENERAL TERMS AND CONDITIONS
Responsibilities:
The Home Depot: will pros ide the Products identified above. make arrangements to has e the Authorized Service Provider perform
the Installation services in a professional and workmanlike manner.and arrange proper insurances. Unless otherwise expressly
provided for herein,Authorized Service Provider will obtain required permits and provide permit numbers.
Customer: will identify any property lines.easements.covenants. underground or overhead utility lines.pre-existing physical or
11/30(12-SA Page 1 of 7
The Commonwealth of Massachusetts
_,== Department of Industrial Accidents
1_
E '-r Office of Investigations
°r 1 Congress Street,Suite 100
" =°��= Boston,MA 02114-2017
"4,r...4'• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): e 7:::)-e---Rcr---
—
Address: �=irsa" `12 jyp' t r+2i i9 l''" `
, ,
City/State/Zip: � ,; j ' :.'/ Phone#: RO--
-'2
Are you an employer?Check the appropriate bo Type of project(required):
1.❑ I am a employer with 4. am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. n New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. n Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for m employees. Below is the policy and job site
information. �-
Insurance Company Name: A !fir /1 a s
p Y ��Lf�f�//
Policy#or Self-ins.Lic.#: . / Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certjf under ti' lir d le Jies o�j' 'ur that the in ormation provided above is true and correct.
Si nature:
//MI",/ rillimir
Date i�f�
Phone#: A -'' _ P _____,l—f ,
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
L
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: J�-y�/) Not Applicable�J1£ /IV Name of License Holder: ; °�'�' v��
License Number
Address ( 1 Expiration Date
Signature Telephone
Not Applicable £
9 :Registered Home Imp%nt C�r ,� _,.,� ......... ........_ ....�. A li P����C'�--�
Registrati n Number
Company N ee1r
.'/ Expiration Date
r1�' /r 05-77115-
Telephonerd/ X2133
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes £ No £
11..= Home Owner.Exmption.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature,
■
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ...I:3-
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [❑] Other[0]
Brief Description of Pr , ' 4--- . '�- ' /3 / -�7�
Work: 4i'l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a,ifNew hOii and iiii ditlonto ezisfinq:.hous `q; colrnpMete the foIlowi64:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 ®/,/,k?
I, _ ,as Owner of the subject
r t
property 4 3 eTP- /
hereby authorize
to act on my behalf, in all m. -rs relative to work authorized by this building permit application.
Signature of Date e?.
I 1f2 r'-1,�c-'�V i' ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed unde��#�e�l s and nalties of p-rjury. R42/19--
oil
A
Print Name
Ade
Yf OP - - 3
Signature of ofner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size I I ! l
Frontage I . _ j - 1 I____ J
Setbacks Front I__J I ii
Side L:1
L:l_.___.._1 R:1 �----1 Fi
Rear t i t""-'-�
Building Height ( '—i I I [ !
Bldg.Square Footage 11 I 'i % F`1 f I _
Open Space Footage € i % _''_'`�
(Lot area minus bldg&paved L_______i L...._._l ,"___I 1
parking)
#of Parking Spaces = I t`----1
Fill: 1 ...,�_....._�.._�._.._.._..._ .. w�._..�._.�._._.._....�...._..�.,__.._...i��_,� .........,._._.�....�..�,_...... r
(volume&Location)
,,
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
� _
IF YES: enter Book Pager and/or Document#r -------11
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: k
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
i's ,T'v ri #a "r 7eparfrpentrUSe Onlyt ,a5 K` V„ ivy '+1
o �n • of Northampton Sfatus,ofPgrmd �, K f '4Y� cgs r rfii3 �'
V y 'k; i fr ,+�+ '"54 4 i� �� �c tr sh'Is l y.a,.s y. # a.
ilding Department Curb Cut/DrlyeuvaPerrrit
q���r� a�t js i � [�e q.�c �,�'--ix .,-, ,.q x.�"`u r,i r4 1 4
212 Main Street ilItr ii00lc Availrt lty atit �7aL 4
il
SEP 1 x �a
2 2013 Room 100 IrYY ate�/l/k�e�f A�vatlaUllit�'�� �`� �c r ar � o n'i�i t�'i}�, ,
Ele •• hampton, MA 01060 TWa sets a1'3#rttctual Plan's iFt "
ctrro 6; 3§,,A 4 4 V x f qq�
N hambpte a si - 13!' 87-1240 Fax 413-587-1272 PIo ISite Plans ,4- y�' 1 fi' ky i �;j �}q ��, 4
oYa6o coons: af: S�SeS t ' qyh �q" y sy. a��x xy J 4�a 11 Eq h {
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
T. s se....:. n
I.,vi,...t...., , ,,,---, it 1.1 Property Address: ction to be complee by fce
iel.flr.1 /-ik-... 17)10 I?6) P17 k
Zone Overlay D�stnct
Elm"St District CB.Distract . .
SECTION 2•-PROPERTY OWNERSHIP/AUTHORIZED AGENT • 1 A�,
2.1 Owner of Record F21941/ (1 �
�?. ✓ ivy
0/D67--
Name(Print) Current Maili/Address:
�,r`G l�vv / Telephone 13 '—J /,-,7�/.[j..J
Signature / — ( �i T
2.2 Auth ized ent: ' � I ,�,�"
Name(Print) Current Mailing A.'re•-.Ifit
/ "--'
r 0/ -- �% ^��C�
Signs re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COS .
TS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
4/ (a)Building Permit Fee
2. Electrical (b)Estimated TotalCost of
1. Building /41 Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) R 41)- — Check Number /5 �-
/L./f/ This Section For Official Use Only
Date
Building Permit Number: . Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
•
120 MAPLEWOOD TER BP-2014-0308
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D- 190 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-0308
Project# JS-2014-000519
Est. Cost: $14754.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 096194
Lot Size(sq. ft.): 6490.44 Owner: EVANS FRANCIS J
Zoning:URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 120 MAPLEWOOD TER
Applicant Address: Phone: Insurance:
24 SUNRISE DR (401) 935-2633 0 Workers Compensation
PROVIDENCERI02908 ISSUED ON:9/12/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 9/12/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner